Ethics in Midwifery Guide Good Decision Making
The practice of midwifery is infused with values that guide the way midwives provide care to women, infants and families. Ethics is a necessary component of midwifery care and requires midwives to make ethical decision on a daily basis regardless of settings in which they provide services, such as clinics, homes, hospitals and birth centers.
The Midwives Alliance Statement of Values and Ethics was written and adopted by the MANA Board of Directors in 1997, and revised and adopted in August 2012.
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MANA Statement of Values and Ethics
The Statement of Values and Ethics of the Midwives Alliance of North America (MANA) is a critical reflection of moral issues as they pertain to maternal and child health. It is intended to provide guidance for professional conduct in the practice of midwifery, as well as influence MANA’s organizational policies, thereby promoting high quality care for childbearing families.
Statement of Values
Since what we value infuses and informs our ethical decisions and actions, the Midwives Alliance of North America affirms:
I. Woman As a Unique Individual:
A. We value each woman as a strong, creative, unique individual with life-giving powers.
B. We value each woman’s right to a supportive caregiver appropriate to her needs and respectful of her belief system.
C. We value a woman’s right to access resources in order to achieve health, happiness and personal growth according to her needs, perceptions and goals.
D. We value a woman as autonomous and competent to make decisions regarding all aspects of her life.
E. We value the empowerment of a woman during the processes of pregnancy, birth, breastfeeding, mother–infant attachment and parenting.
II. Mother and Baby as Whole:
A. We value the mother and her baby as an inseparable and interdependent whole and acknowledge that each woman and baby have parameters of well-being unique to themselves.
B. We value the physical, psychosocial and spiritual health, well-being and safety of every mother and baby.
C. We value the mother as the direct care provider for her unborn child.
D. We value the process of labor and birth as a rite of passage with mother and baby as equal participants.
E. We value the sentient and sensitive nature of the newborn and affirm every baby’s right to a caring and loving birth without separation from mother and family.
F. We value breastfeeding as the ideal way to nourish and nurture the newborn.
III. The Nature of Birth:
A. We value the essential mystery of birth.
B. We value pregnancy and birth as natural, physiologic and holistic processes that technology will never supplant.
C. We value the integrity of a woman’s body, the inherent rhythm of each woman’s labor and the right of each mother and baby to be supported in their efforts to achieve a natural, spontaneous vaginal birth.
D. We value birth as a personal, intimate, internal, sexual and social experience to be shared in the environment and with the attendants a woman chooses.
E. We value the right of a woman and her partner to determine the most healing course of action when difficult situations arise.
F. We value the art of letting go and acknowledge death and loss as possible outcomes of pregnancy and birth.
IV. The Art of Midwifery:
A. We value our right to practice the art of midwifery, an ancient vocation of women.
B. We value multiple routes of midwifery education and the essential importance of apprenticeship training.
C. We value the wisdom of midwifery, an expertise that incorporates theoretical and embodied knowledge, clinical skills, deep listening, intuitive judgment, spiritual awareness and personal experience.
D. We value the art of nurturing the inherent normalcy of pregnancy and birth as expressions of wellness in a healthy woman.
E. We value continuity of care throughout the childbearing year.
F. We value birth with a midwife in any setting that a woman chooses.
G. We value homebirth with a midwife as a wise and safe choice for healthy families.
H. We value caring for a woman to the best of our ability without prejudice with regards to age, race, ethnicity, religion, education, culture, sexual orientation, gender identification, physical abilities or socioeconomic background.
I. We value the art of empowering women, supporting each to birth unhindered and confident in her natural abilities.
J. We value the acquisition and use of skills that identify and guide a complicated pregnancy or birth to move toward greater well-being and be brought to the most healing conclusion possible.
K. We value standing up for what we believe in the face of social pressure and political oppression.
V. Woman as Mother:
A. We value a mother’s intuitive knowledge and innate ability to nurture herself, her unborn baby and her newborn baby.
B. We value the power and beauty of a woman’s body as it grows in pregnancy and a woman’s strength in labor and birth.
C. We value pregnancy and birth as processes that have lifelong impact on a woman’s self-esteem, her health, her ability to nurture and her personal growth.
D. We value the capacity of partners, family and community to support a woman in all aspects of pregnancy, birth and mothering and to provide a safe environment for mother and baby.
VI. The Nature of Relationship:
A. We value an egalitarian relationship between a woman and her midwife.
B. We value the quality, integrity and uniqueness of our interactions, which inform our choices and decisions.
C. We value mutual trust, honesty and respect.
D. We value a woman’s right to privacy, and we honor the confidentiality of all personal interactions and health records.
E. We value direct access to information that is readily understood by all.
F. We value personal responsibility and the right of a woman to make decisions regarding what she deems best for herself, her baby and her family, using both informed consent and informed refusal.
G. We value our relationship to a process that is larger than ourselves, recognizing that birth is something we can seek to learn from and to know, but cannot control.
H. We value humility and the recognition of our own limitations.
I. We value sharing information and understanding about birth experiences, skills and knowledge.
J. We value a supportive midwifery community as an essential place of learning.
K. We value diversity among midwives that broadens our collective resources and challenges us to work toward greater understanding.
L. We value collaboration between a midwife and other health-care practitioners as essential to providing a family with resources to make responsible and informed choices.
M. We value the right and responsibility of both a midwife and a woman to discontinue care when insurmountable obstacles develop that compromise communication, mutual trust or joint decision making.
N. We value the responsibility of a midwife to consult with other health-care practitioners when appropriate and refer or transfer care when necessary.
VII. Cultural Sensitivity, Competency and Humility
A. We value cultural sensitivity, competency and humility as critical skills for the midwife to master in an increasingly multicultural society.
B. We value cultural sensitivity—a midwife’s awareness of and ability to honor differences between people and the cultural values of the women she serves.
C. We value the importance of cultural competency in addressing the social and economic barriers to access to care for vulnerable, underserved and marginalized women, thereby improving maternal and infant health and the well-being of families.
D. We value cultural humility as a lifelong process of self-reflection and self-critique in order to develop a respectful partnership with each woman.*
*Section VII is derived from Melanie Tervalon and Jann Murray-Garcia, “Cultural Humility versus Cultural Competency: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education,” Journal of Health Care for the Poor and Underserved 9 (May 1998): 117–25.
Statement of Ethics
Our values inform and inspire midwifery practice in our hearts and minds. Acting ethically is an expression of our values within the context of our individual, geographic, religious, cultural, ethnic, political, educational and personal backgrounds and in our relationships with others. As we seek to respond in the moment to each situation we face, we call upon ethical principles of human interaction as follows:
- Beneficence—to act so as to benefit others
- Nonmaleficence—to avoid causing harm
- Confidentiality—to honor others’ privacy and keep personal interactions confidential
- Justice—to treat people respectfully and equitably
- Autonomy—to respect an individual’s rights to self-determination and freedom to make decisions that affect his or her life.
The equality and mutuality of the relationship between midwife and client create a foundation uniquely suited to integrate these principles. As midwives, we seek to benefit women and babies in our care. Mutual trust and respect are critical to the success of a relationship that requires joint decision making at every level. Moral integrity, truthfulness and adequate information enable all participants to judge together the best course of action in varied situations.
Judgments are fundamentally based on awareness and understanding of ourselves and others. They grow out of our own sense of moral integrity, which is born within the heart of each individual. Becoming self-aware and increasing understanding are ongoing processes that must be nurtured as a function of personal and professional growth. MANA’s affirmation of individual moral integrity and recognition of the complexity of life events bring us to an understanding that there cannot possibly be one right answer for all situations. Since the outcome of pregnancy is ultimately unknown and is always unknowable, it is inevitable that in certain circumstances our best decisions in the moment will lead to consequences we could not foresee.
We recognize the limitations of traditional codes of ethics that present a list of rules to be followed. Therefore, a midwife must develop a moral compass to guide practice in diverse situations that arise from the uniqueness of pregnancy and birth as well as the relationship between midwives and birthing women. This approach affirms the mystery and potential for transformation present in every experience and fosters truly diverse practice. Midwifery care is woman-led care with informed choice and a clear set of values at its core. Decision making is a shared responsibility with the goals of healthy women and babies and of gentle, empowering births with a focus on individual and family needs and concerns. Ultimately, it is at the heart of midwifery practice to honor and respect the decisions women make about their pregnancies and births based on their knowledge and belief about what is best for themselves and their babies.
There are both individual and social implications to any decision-making process. Our decisions may be impacted by the oppressive rules and practices of a society that is often hostile to homebirth, midwives and midwifery clients. Our actual choices may be limited by the medical, legal, political, economic, cultural or social climate in which we function. The more our values conflict with those of the dominant culture, the greater the threat to the integrity of our own values, and the greater the risk that our actions may lead to professional repercussions or legal reprisal. In such conditions we may be unable to make peace with any course of action or may feel conflicted about a choice already made. The community of women, both midwives and those we serve, may provide a fruitful resource for continued moral support and guidance.
In summary, acting ethically requires us to define our values, respond to the communities of families, midwives and cultures in which we find ourselves, act in accord with our values to the best of our ability as the situation demands, and engage in ongoing self-examination, evaluation, peer review and professional growth. By carefully describing the multifaceted aspects of what we value and defining the elements of moral integrity and decision making, we have created a framework for ethical behavior in midwifery practice. We welcome an open and ongoing articulation of values and ethics and the evolution of this document.